BackgroundInsulinoma is a rare tumour representing 1–2% of all pancreatic neoplasms and it is malignant in only 10% of cases. Locoregional invasion or metastases define malignancy, whereas the dimension (> 2 cm), CK19 status, the tumor staging and grading (Ki67 > 2%), and the age of onset (> 50 years) can be considered elements of suspect.Case presentationWe describe the case of a 68-year-old man presenting symptoms compatible with hypoglycemia. The symptoms regressed with food intake. These episodes initially occurred during physical activity, later also during fasting. The fasting test was performed and the laboratory results showed endogenous hyperinsulinemia compatible with insulinoma. The patient appeared responsive to somatostatin analogs and so he was treated with short acting octreotide, obtaining a good control of glycemia. Imaging investigations showed the presence of a lesion of the uncinate pancreatic process of about 4 cm with a high sst2 receptor density. The patient underwent exploratory laparotomy and duodenocephalopancreasectomy after one month.The definitive histological examination revealed an insulinoma (T3N1MO, AGCC VII G1) with a low replicative index (Ki67: 2%).ConclusionsThis report describes a case of malignant insulinoma responsive to octreotide analogs administered pre-operatively in order to try to prevent hypoglycemia. The response to octreotide analogs is not predictable and should be initially assessed under strict clinical surveillance.

Objective Incidental diagnosis of thyroid nodules, and therefore of thyroid cancer, has definitely increased in recent years, but the mortality rate for thyroid malignancies remains very low. Within this landscape of overdiagnosis, several nodule ultrasound scores (NUS) have been proposed to reduce unnecessary diagnostic procedures. Our aim was to verify the suitability of five main NUS. Methods This single-center, retrospective, observational study analyzed a total number of 6474 valid cytologies. A full clinical and US description of the thyroid gland and nodules was performed. We retrospectively applied five available NUS: KTIRADS, ATA, AACE/ACE-AME, EUTIRADS, and ACRTIRADS. Thereafter, we calculated the sensitivity, specificity, PPV, and NPV, along with the number of possible fine-needle aspiration (FNA) sparing, according to each NUS algorithm and to clustering risk classes within three macro-groups (low, intermediate, and high risk). Results In a real-life setting of thyroid nodule management, available NUS scoring systems show good accuracy at ROC analysis (AUC up to 0.647) and higher NPV (up to 96%). The ability in FNA sparing ranges from 10 to 38% and reaches 44.2% of potential FNA economization in the low-risk macro-group. Considering our cohort, ACRTIRADS and AACE/ACE-AME scores provide the best compromise in terms of accuracy and spared cytology. Conclusions Despite several limitations, available NUS do appear to assist physicians in clinical practice. In the context of a common disease, such as thyroid nodules, higher accuracy and NPV are desirable NUS features. Further improvements in NUS sensitivity and specificity are attainable future goals to optimize nodule management. Key Points • Thyroid nodule ultrasound scores do assist clinicians in real practice. • Ultrasound scores reduce unnecessary diagnostic procedures, containing indolent thyroid microcarcinoma overdiagnosis. • The variable malignancy risk of the “indeterminate” category negatively influences score’s performance in real-life management of thyroid lesions.

Context Despite the wide revision of current guidelines, the management of papillary thyroid microcarcinoma (mPTC) has still to be decided case-by-case. There is conflicting evidence about the role of more frequent histological subtypes and no data about potential differences at presentation. Objective Our aim was to compare the phenotype of the two most frequent mPTC variants, i.e. classic (mPTCc) and follicular (mFVPTC) variants of mPTC. Design Retrospective observational study, from January 2008 to December 2017. Patients A consecutive series of mPTCc and mFVPTC. Measures All cases were classified according to the 2015 ATA risk classification. Clinical and preclinical features of mPTCc and mFVPTC at diagnosis were collected. The comparison was also performed according to the incidental/non-incidental diagnosis and differences were verified by binary logistic analysis. Results A total sample of 235 patients was eligible for the analysis (125 and 110 mPTCc and mFVPTC, respectively). As compared with mPTCc, mFVPTC were more often incidental and showed significantly smaller size (4 vs. 7 mm) (p < 0.001 all), possibly influenced by the higher rate of incidental detection. mFVPTC and incidental (p < 0.001 both) tumours were significantly more often allocated within the Low risk class. A logistic regression model, having ATA risk class as dependent variable, showed that both mFVPTC [O.R. 0.465 (0.235-0.922); p = 0.028], and incidental diagnosis [O.R. 0.074 (0.036-0.163); p < 0.001], independently predicted the ATA risk stratification. Conclusions mFVPTC shows some differences in diagnostic presentation as compared to mPTCc, and seems to retain a significant number of favourable features, including a prevalent onset as incidental diagnosis.